HPV ctDNA detection of high-risk HPV types during chemoradiotherapy for locally advanced cervical cancer

BACKGROUND

Chemoradiotherapy (CRT) is the standard of care for patients diagnosed with locally advanced cervical cancer (LACC), a human papillomavirus (HPV)-related cancer that relapses in 30%-60% of patients. This study aimed to (i) design HPV droplet digital PCR (ddPCR) assays for blood detection (including rare genotypes) and (ii) monitor blood HPV circulating tumor DNA (HPV ctDNA) levels during CRT in patients with LACC.

METHODS

We analyzed blood and tumor samples from 55 patients with HPV-positive LACC treated by CRT in a retrospective cohort (n = 41) and a prospective cohort (n = 14). HPV-ctDNA detection was carried out by genotype-specific ddPCR.

RESULTS

HPV ctDNA was successfully detected in 69% of patients (n = 38/55) before CRT for LACC, including nine patients with a rare genotype. HPV-ctDNA level was correlated with HPV copy number in the tumor (r = 0.41, P < 0.001). HPV-ctDNA positivity for HPV18 (20%, n = 2/10) was significantly lower than for HPV16 (77%, n = 27/35) or other types (90%, n = 9/10, P = 0.002). HPV-ctDNA detection (positive versus negative) before CRT was associated with tumor stage (P = 0.037) and lymph node status (P = 0.02). Taking into account all samples from the end of CRT and during follow-up in the prospective cohort, positive HPV-ctDNA detection was associated with lower disease-free survival (DFS) (P = 0.048) and overall survival (OS) (P = 0.0013).

CONCLUSION

This is one of the largest studies to report HPV-ctDNA detection before CRT and showed clearance of HPV ctDNA at the end of treatment in most patients. Residual HPV ctDNA at the end of CRT or during follow-up could help to identify patients more likely to experience subsequent relapse.

A multivariate Th17 metagene for prognostic stratification in T cell non-inflamed triple negative breast cancer

A diversity of T helper (Th) subsets (Th1, Th2, Th17) has been identified in the human tumor microenvironment. In breast cancer, the role of Th subsets remains controversial, and a systematic study integrating Th subset diversity, T cell inflammation, breast cancer molecular subtypes, and patient prognosis, is lacking. In primary untreated breast cancer samples, we analyzed 19 Th cytokines at the protein level. Eight were T cell-specific, and subsequently measured in 106 prospectively-collected untreated samples. The dominant Th cytokines across all breast cancer samples were IFN-γ and IL-2. Th2 cytokines (IL-4, IL-5, IL-13) were expressed at low levels and not associated with any breast cancer subtype. Th17 cytokines (IL-17A and IL-17F) were up-regulated in triple negative breast cancer (TNBC), specifically in T cell non-inflamed tumors. In order to get insight into prognosis, we exploited the METABRIC transcriptomic dataset. We derived Th1, Th2, and Th17 metagenes based on manually curated Th signatures, and found that a high Th17 metagene was of good prognosis in T cell non-inflamed TNBC. Multivariate Cox modeling selected the Nottingham Prognostic Index (NPI), Th2 and Th17 metagenes as additive predictors of breast cancer-specific survival, which defined novel and highly distinct prognostic groups within TNBC. Our results reveal that Th17 is a novel prognostic composite biomarker in T cell non-inflamed TNBC.

Integrating immune cell and tumor molecular diversity is an efficient strategy for prognostic stratification of cancer patients.

[The role of nipple-sparing mastectomy in breast cancer: a comprehensive review of the literature]

BACKGROUND

The role of nipple-sparing mastectomy (NSM) for breast cancer is controversial as there is concern regarding its oncological safety and complication rate. We carried out a review of the literature to quantify the incidence of occult nipple malignancy in breast cancer, identify the factors influencing occult nipple malignancy, quantify locoregional recurrence rates and quantify NSM complication rates.

METHODS

A search of the literature was performed using PubMed. Keywords used were "mastectomy", "nipple involvement", "nipple-sparing mastectomy", "skin-sparing mastectomy" "occult nipple malignancy" "occult nipple disease" "breast cancer recurrence". Articles were analyzed regarding incidence of occult nipple malignancy, potential factors influencing the incidence of occult malignancy and recurrence/complications following NSM. The incidence of occult nipple disease was compared between groups using Chi(2) or Fisher's exact tests for categorical variables and Student's t-tests for continuous variables. P values were considered significant<0.05. We identified nearly 30 studies compiling nearly 10 000 cases examining the rate of occult nipple malignancy and 23 studies compiling 2300 cases providing information on the rate of local recurrence after NSM.

RESULTS

The overall rate of occult nipple malignancy was 11.5 %. Primary tumour characteristics influencing occult nipple malignancy were tumour-nipple distance<2cm, grade, lymph node metastasis, lymphovascular invasion, HER2 positive, ER/PR negative, tumour size>5cm, retro-areolar/central location and multicentric tumours. The overall nipple recurrence rate following NSM was 0.9 %, skin flap recurrence rate was 4.2 %. Full and partial thickness nipple necrosis rates were 2.9 % and 6.3 % respectively.

CONCLUSION

NSM for primary breast cancer is appropriate in carefully selected patients. All patients should have retro-areolar sampling. There is strong evidence to suggest that suitable cases are well circumscribed single or multifocal lesions that have a TND>2cm. Tumours should be graded 1-2 and not have LVI, axillary node metastasis or HER2 positivity.

Clinico-pathology and prognosis of endometrial cancer in patients previously treated for breast cancer, with or without tamoxifen: a comparative study in 363 patients

OBJECTIVE

To compare the clinic-pathologic variables and the prognosis of endometrial cancer in patients with and without previous breast cancer, with and without Tamoxifen.

METHODS

We analyzed patients treated for an endometrial carcinoma from 1994 to 2004: patients without breast cancer (group 1), patients with a previous breast cancer without tamoxifen (group 2) and patients treated for breast cancer with tamoxifen (group 3). Survival rates were calculated according to Kaplan-Meier method and compared using a Log rank test, multivariate analysis was performed with a Cox regression model.

RESULTS

363 patients were analyzed. 80 patients had a previous history of breast cancer (43 received tamoxifen). Although it was not statistically significant, more carcinosarcomas were observed in patients in group 3 than patients in groups 1 and 2 (11.7% versus 4.2% and 5.4% respectively, p = 0.17).) Median follow-up was 87 months [2-185]. 5-year overall survival rate was respectively in groups 1, 2 and 3: 82%, 73.2%, and 61% (p = 0.0006). 5-year local relapse-free survival rate was respectively: 95.9%, 93.1% and 82.5% (p = 0.02). In multivariate analysis, factors affecting overall survival rate were: age ≥65 ans (HR 3.62, p < 0.0001), FIGO stage (HR 3.33 p < 0.0001 for locally advanced stage versus early stage, HR 8.87 p = 0.03 for distant extension versus early stage), and group 3 (HR 2.83 p < 0.001 versus group 1).

CONCLUSION

Patients with endometrial cancer previously treated for breast cancer show a worse prognostic, particularly if they reveived tamoxifen.

Extensive pure ductal carcinoma in situ of the breast: identification of predictors of associated infiltrating carcinoma and lymph node metastasis before immediate reconstructive surgery

AIM

To identify predictors for infiltrating carcinoma and lymph node involvement, before immediate breast reconstructive surgery, in patients with an initial diagnosis of extensive pure ductal carcinoma in situ of the breast (DCIS).

PATIENTS AND METHODS

Between January 2000 and December 2009, 241 patients with pure extensive DCIS in preoperative biopsy had underwent mastectomy. Axillary staging (sentinel node and/or axillary dissection) was performed in 92% (n = 221) of patients. Patients with micro-invasive lesions at initial diagnosis, recurrence or contralateral breast cancer were excluded.

RESULTS

Respectively 14% and 21% of patients had a final diagnosis of micro-invasive carcinoma (MIC) and invasive ductal carcinoma (IDC). Univariate analysis showed that the following variables at diagnosis were significantly correlated with the presence of either MIC or IDC in the mastectomy specimen: palpable tumor (p = 0.002), high grade DCIS (p = 0.002) and detection of an opacity by mammography (p = 0.019). Axillary lymph node (ALN) involvement was reported in 9% of patients. Univariate analysis suggested that a body mass index higher than 25 (p = 0.007), a palpable tumor (p = 0.012) and the detection of an opacity by mammography (p = 0.044) were associated with an increased rate of ALN involvement.

CONCLUSION

Skin-sparing mastectomy and immediate breast reconstruction (IBRS) has become increasingly popular, especially for patients with extended DCIS of the breast. This study confirmed that extended DCIS is associated with a substantial risk of finding MIC or IDC on the surgical specimen but also ALN involvement. Adjuvant systemic treatment and/or radiotherapy could be indicated for some of these patients after the surgery. Patients should be informed of the rate of 1) complications associated to IBRS that will potentially delay the introduction of systemic or local therapy 2) complications associated to radiotherapy after IBRS.

Prediction of axillary lymph node status in male breast carcinoma

BACKGROUND

To evaluate whether predictive factors of axillary lymph node metastasis in female breast cancer (BC) are similar in male BC.

PATIENTS AND METHODS

From January 1994 to May 2011, we recorded 80 non-metastatic male BC treated at Institut Curie (IC). We analysed the calibration and discrimination performance of two nomograms [IC, Memorian Sloan-Kettering Cancer Center (MSKCC)] originally designed to predict axillary lymph node metastases in female BC.

RESULTS

About 55% and 24% of the tumours were pT1 and pT4, respectively. Nearly 46% demonstrated axillary lymph node metastasis. About 99% were oestrogen receptor positive and 94% HER2 negative. Lymph node status was the only significant prognostic factor of overall survival (P = 0.012). The area under curve (AUC) of IC and MSKCC nomograms were 0.66 (95% CI 0.54-0.79) and 0.64 (95% CI 0.52-0.76), respectively. The calibration of these two models was inadequate.

CONCLUSIONS

Multi-variate models designed to predict axillary lymph node metastases for female BC were not effective in our male BC series. Our results may be explained by (i) small sample size (ii) different biological determinants influencing axillary metastasis in male BC compared with female BC.

Abstract P1-01-19: Prediction of axillary lymph node status in male breast carcinoma

Background: To evaluate whether predictive factors of axillary lymph node metastasis in female breast cancer (BC) are similar in male BC.

Patients and methods: From January 1994 to May 2011, we recorded 80 non-metastatic male BC treated at Institut Curie. We analysed the calibration and discrimination performance of two nomograms (Institut Curie (IC), Memorian Sloan-Kettering Cancer Center (MSKCC)) originally designed to predict axillary lymph node metastases in female BC.

Results: 55% and 24% of the tumours were pT1 and pT4 respectively. 46% demonstrated axillary lymph node metastasis. 99% were estrogen receptor positive and 94% HER2 negative. Lymph node status was the only significant prognostic factor of overall survival (p = 0.012). The area under curve (AUC) of IC and MSKCC nomograms were 0.66 (95%CI, 0.54–0.79) and 0.64 (95% CI, 0.52–0.76) respectively. The calibration of these two models was inadequate (Table 1).

[A case of cutaneous mammary re-irradiation]

In early-stage breast cancer, radiotherapy delivered after conservative surgery leads to a reduction in the risk of local recurrences by approximately two thirds. However, some local recurrences can occur in a previously irradiated region and be relevant for a second radiotherapy, exposing to an increased risk of adverse effects. We describe here the observation of a 66-year-old woman treated for a triple negative ductal infiltrative carcinoma of the left breast, who presented an early locoregional recurrence, notably as skin nodules, developed within the irradiated volume and progressing on chemotherapy. The patient was treated by re-irradiation performed concomitantly to oral chemotherapy by capecitabine.

Validation over time of a nomogram including HER2 status to predict the sentinel node positivity in early breast carcinoma

BACKGROUND

The molecular subtypes of breast cancer have different axillary status. A nomogram including the interaction covariate between estrogen receptor (ER) and HER2 has been recently published (Reyal et al. PLOS One, May 2011) and allows to identify the patients with a high risk of positive sentinel lymph node (SLN). The purpose of our study was to validate this model on an independent population.

METHODS

We studied 755 consecutive patients treated at Institut Curie for operable breast cancer with sentinel node biopsies in 2009. The multivariate model, including age, tumor size, lymphovascular invasion and interaction covariate between ER and HER2 status, was used to calculate the theoretical risk of positive sentinel lymph node (SLN) for all patients. The performance of the model on our population was then evaluated in terms of discrimination (area under the curve AUC) and of calibration (Hosmer-Lemeshow HL test).

RESULTS

our population was significantly different from the training population for the following variables: median tumor size in mm, lymphovascular invasion, positive ER and age. The nomogram showed similar results in our population than in the training population in terms of discrimination (AUC=0.72 [0.68-0.76] versus 0.73 [0.7-0.75] and calibration (HL p=0.4 versus p=0.35).

CONCLUSIONS

Despite significant differences between the two populations concerning variables which are part of the nomogram, the model was validated in our population. This nomogram is robust over time to predict the likelihood of positive SLN according to molecular subtypes defined by surrogate markers ER and HER2 determined by immunohistochemistry in clinical practice.

PD02-08: Validation over Time of a Nomogram Predicting the Sentinel Node Positivity in Early Breast Carcinoma According to the Molecular Subtypes Classification

Background: The molecular subtypes of breast cancer have different axillary status. A new nomogram including the interaction covariate between estrogen receptor (ER) and HER2 status has been recently published (Reyal et al. PLOSone, may 2011) and allows to identify before surgery the patients with a high risk of positive sentinel lymph node (SLN). The purpose of our study was to validate this model on an independent population.

Patients and methods: We studied 755 consecutive patients treated for operable breast cancer with sentinel node biopsies in 2009, from the Institut Curie breast cancer prospective database. Baseline characteristics were compared between our population and the population used to build the model, using Chi-square test for categorical variables and Kruskal-Wallis test for continuous variables. The multivariate model, including age, tumor size, lymphovascular invasion and interaction covariate between ER and HER2 status, was used to calculate the theoretical risk of positive sentinel lymph node (SLN) for all patients. The performance of the model on our population was then evaluated in terms of discrimination (area under the curve AUC) and of calibration (Hosmer-Lemeshow HL test).

Results: Characteristics of our population were significantly different from the training population for the following variables: tumor size (median 12mm [1-60] versus 13mm [1-100] p=0.005), lymphovascular invasion (18.6% versus 23.7% p=0.006), positive ER (91.4% versus 87% p=0.002) and age as followed: 56.7% of patients ≤ 60 versus 63.1%, 17.5% of patients between 60 and 65 versus 14.1% and 25.8% of patients above 65 versus 22.8% p=0.01. The nomogram showed similar results in our population than in the training population in terms of discrimination (AUC= 0.72 [0.68−0.76] versus 0.73 [0.7−0.75] and calibration (HL p= 0.4 versus p=0.35).

Conclusions: Despite significant differences between the two populations concerning variables which are part of the nomogram, the model was validated in our population. Our study shows that this nomogram is efficient and robust over time to predict the likelihood of positive SLN according to molecular subtypes defined by surrogate markers ER and HER2 determined by immunohistochemistry in clinical practice.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr PD02-08.

P3-07-09: Prediction of Additional Nodal Metastasis in Breast Cancer Patients with a Positive Sentinel Node Biopsy: A New Nomogram Including HER2 Status

Background

The Memorial Sloan Kettering Cancer Center-Breast Cancer Nomogram (MSKCC-BCN) predicts additional nodal metastasis in patients with positive sentinel lymph node (SLN). This statistical tool does not include HER2 status. It has been shown that the interaction covariate between estrogen receptor (ER) and HER2 status was a determinant of SLN positivity. The purpose of our study was to determine if the accuracy of MSKCC BCN could be enhanced with new variables.

Patients and methods: Our dataset consisted of 2769 consecutive patients treated for operable breast cancer with SLN biopsies between 2006 and 2009. We selected all the patients (n = 588) with a positive SLN who underwent a completion axillary lymph node dissection (ALND). The MSKCC-BCN was used to calculate the theoretical risk of additional nodal metastasis for all patients. The evaluation of the MSKCC-BCN was performed with calibration test (Cox method) and performance test (Bleeker). Multivariate analysis used a logistic regression model. The input was based on the variables found significant in the univariate analysis. Interaction covariate between ER and HER2 status was included in the model. Our model was then analyzed in terms of discrimination (area under the curve) and of calibration (Hosmer-Lemeshow test).

Results: Calibration test showed significant differences between the probability of additional nodal disease predicted by the MSKCC-BCN and the probability observed in our population for the following subgroups of patients: histological grade 3 (p= 0.007), lymphovascular invasion (p=0.03), multifocality (p=0.04), positive ER (p=0.002), micrometastasis in the SLN (p=0.003), isolated tumor cells in the SLN (p=0.02 and positive HER2 (p=0.01). Performance test showed significant differences for the following variables: histological grade (p= 0.02), size of the SLN metastasis (p=0.04) and HER2 status (p=0.01). This shows that the MSKCC-BCN is not well calibrated and cannot be used for our population. A multivariate model to determine the probability of additional nodal metastasis was defined with the following variables: pathologic size of the sentinel node metastasis, interaction covariate between the ER and HER2 status, number of positive SLN and number of SLN removed [Table 1].

Necrosis in breast cancer patients with skin metastases receiving bevacizumab-based therapy

OBJECTIVE

Bevacizumab has entered daily practice in advanced breast cancer patients, in whom skin metastases occurrence is a common event. Wound healing impairment has been described with bevacizumab, and this study looks at possible deleterious side effects of bevacizumab in patients with skin metastases.

METHOD

We retrospectively reviewed a series of 12 patients with advanced breast cancer presenting extensive skin metastases, and who received bevacizumab based therapy.

RESULTS

Nine patients who initially presented with erosive skin lesions developed extensive and durable skin necrosis, as well as delayed healing of surgical flaps, despite early discontinuation of bevacizumab therapy and intensive skin care in a specialised unit. Skin necrosis was usually associated with extensive tumoural involvement of the skin.

CONCLUSION

Bevacizumab may be harmful in selected breast cancer patients with metastatic cutaneous involvement.

Outcome in early cervical cancer following pre-operative low dose rate brachytherapy: a ten-year follow up of 257 patients treated at a single institution

OBJECTIVE

To report the outcome of preoperative low dose rate uterovaginal brachytherapy (LDR-UVBT) followed by radical surgery in the treatment of early cervical carcinoma.

METHODS

257 patients treated at Institut Curie from 1985 to 2008 for cervical carcinoma less than 4cm (FIGO stages Ib1, IIA and IIB) were studied. Patients received preoperative LDR-UVBT followed by hysterectomy Piver II type, with pelvic lymph nodes dissection (PLND). Predictive factors for pathological response to brachytherapy were analyzed with logistic regression, as well as survival rates.

RESULTS

44% of patients had residual tumor, 4.3% of patients had parametrial invasion and 17.9% of patients had lymph node involvement. Predictive factors for an incomplete pathological response were: initial clinical tumor size 20mm (OR 2.1), pN1 (OR 2.77), glandular carcinoma (OR 2.51) and lymphovascular invasion (OR 4.35). 7.4% and 2.7% of patients had respectively grade 2 and grade 3 post-therapeutic late complications. Median follow up was 122 months [1-282]. Five-year actuarial overall survival and disease free survival were respectively 83% CI [78.3-87.5] and 80.9% CI [76.3-85.7]. In multivariate analysis, factors affecting significantly the overall survival and disease free survival rates were: lymph node involvement (RR 4.53 and 8.96 respectively), parametrial involvement (RR 5.69 and 5.62 respectively), smoking (RR 3.07 and 2.63 respectively).

CONCLUSIONS

Preoperative LDR-UVBT results in good disease control with a low complications rate. Its accuracy could be improved by a better selection of patients. Lymph nodes and parametrial evaluation remains a challenging issue that should be achieved with imaging and minimal invasive surgery.

Abstract P2-16-09: Wound Healing and Catheter Thrombosis after Implantable Venous Access Device Placement in 266 Metastatic Breast Cancer Patients Treated with Bevacizumab

OBJECTIVES: To determine in a population of metastatic breast cancer the incidence of wound dehiscence after placement of an implantable venous access device (VAD) in patients treated with bevacizumab, observe the optimum interval between placement and initiation of treatment and study the risk of catheter thrombosis.

PATIENTS AND METHODS: Between 1/1/2007 and 31/12/2009, this study enrolled all VADs placed by 14 anesthetists: 273 VADs in patients treated by bevacizumab for metastatic breast cancer and 4196 VADs in patients not treated by bevacizumab. The medical charts of the 266 metastatic breast cancer patients treated with bevacizumab between 1/1/2007 and 31/12/2009 were reviewed up until 1/3/2010. A VAD was placed in all patients (goal standard in our institution). 7 patients in whom the VAD was inserted in another institution were excluded from this study. The VAD was removed and replaced in 14 patients with continuation of bevacizumab after replacement of the VAD

RESULTS: 1 patient was lost to follow-up. Thirteen cases of wound dehiscence occurred in 12 patients requiring removal of the VAD (5,1 %). All cases of dehiscence occurred when bevacizumab was administered during the first 7 days after VAD placement. Bevacizumab therapy was initiated less than 7 days after VAD placement in 150 cases, requiring removal of the device in 12 patients (8.6%). The risk of dehiscence was the same from 0 to 7 days. In parallel, the VAD wound dehiscence rate in patients not receiving bevacizumab was 8/4,197 (0.19%) (Fisher's test significant, P&lt;0.001). No risk factors were identified: anesthetists, learning curves, irradiated patients. In particular, 70 ports were placed by juniors with 6 dehiscences, 80 ports by seniors with 7 dehiscences. VAD thrombosis occurred in 4 patients (1,5 %) 3, 5, 7 and 22 months after VAD placement. In all these cases, VAD placement was at the time of initiation of bevacizumab therapy. In parallel, VAD thrombosis occurred in 51/4,197 (1.2%) patients not receiving bevacizumab (Fisher's test not significant; p=0.43).

The other indications for VAD removal were end of treatment: 3 (0,91 %), mechanical problem other than thrombosis: 6 (1,8 %), local infection without wound dehiscence: 1 (0,31%). Bevacizumab was permanently discontinued in 5 patients related to wound dehiscence and in 1 patient due to extensive skin necrosis. Bevacizumab was continued in the other 7 patients.

CONCLUSION: The risk of VAD thrombosis does not require any particular primary prevention. These data suggest the need to observe an interval of at least 7 days between VAD placement and initiation of bevacizumab therapy. Poor healing is a major complication of VAD, interfering with continuation of chemotherapy and the patient's subsequent management, resulting in a real risk of loss of chance.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P2-16-09.

Abstract S5-1: Prospective Outcomes for Patients with Micro-Metastases and Macro-Metastases In Sentinel Nodes: NSABP B-32 Sentinel Node Trial

Background: Sentinel node biopsy (SNB) allows for a more detailed analysis of axillary nodes, increasing the detection of nodal metastatic disease. Prospective outcome results related to patients with micro-and macro-metastases in sentinel nodes from the NSABP B-32 trial are presented here.

Methods: After stratification, women with operable invasive breast cancer and clinically negative nodes were randomly assigned to sentinel node resection (SNR) with immediate conventional axillary dissection (AD) [Group 1] or to SNR without AD [Group 2]. Group 2 patients with positive SNs underwent AD. Sentinel nodes underwent analysis by hematoxylin and eosin. Systemic therapy was at the discretion of the physician. Regional nodal irradiation for node positive lumpectomy patients and chest wall/regional node irradiation for node positive mastectomy patients was permitted. Univariate and multivariate analyses were carried out via Cox PH models to identify predictors of overall survival (OS) and disease-free survival (DFS).

Results: From May 1999 through February 2004, 5,611 patients were entered into NSABP B-32. A total 1,390 patients with positive SN were identified; 1,389 of these patients had follow-up data. There were 422 patients with macro-metastases (&gt;2mm), 312 with micro-metastases (&gt;0.2, ≥2.0mm), and 626 with unknown status. Median time in study was 94 months. 97% of SN-positive patients received systemic adjuvant therapy. Significant univariate predictors of OS and DFS were age, receptor status, clinical tumor size, histologic grade, number of positive SNs, SN metastasis size, number of positive nodes, lymphovascular invasion, and systemic therapy. Multivariate analysis identified histologic grade (HR: 2.30, P&lt;0.0001), SN macrometastasis (HR: 2.44, p=0.0003), systemic therapy (HR: 0.22, P&lt;0.0001), age, and clinical tumor size (CTS) as significant predictors of OS (Table 1) with similar predictors for DFS. For DFS, a significant quadratic effect due to age (p=0.015) was observed where younger and older women had higher risk of having an event than did middle aged women.

Conclusion: The most striking factors associated with poor OS and DFS were poor histologic tumor grade and macro-versus micro-SN metastases. Patients with micro-or macro-SN metastases who received systemic therapy had a 78% reduction in mortality and a 76% improvement of DFS.

Supported by: NCI U10-CA-69651, -12027, -37377, -69974.

Distant Metastasis Free Survival (DMFS) in Breast Cancer Patients with Micrometastases (pN1mi) in the Sentinel Lymph Node (SLN): Results in 582 Positive-SLN Patients in a Single Institution

Background:The risk of developing distant metastases (DM) in pN1mi and isolated tumor cells (pN0i+) patients remains under question. Does occult axillary node metastases is an additional factor for using an adjuvant systemic therapy (AST) in early breast cancer ?Patients and Methods:Among 2695 patients operated on from 2000 to 2006 for SLN, 582 patients had a positive SNB: 307 were pN1, 154 pN1mi and 121 pN0i+ (6th AJCC-classification). All patients underwent an immediate or delayed Axillary Lymph Node Dissection (ALND). We report the results for DMFS [median follow-up of 56 months (2-105)].We used Kaplan-Meier method and Cox regression for multivariate analysis.Results:ALND were positive in pN1, pN1mi and pN0i+ patients respectively in 127 (41,3%), 20 (13%) and 14 (11.6%) of these patients. On univariate and multivariate analysis, positive ALND, mitotic index, pathologic tumor size were significantly related to the DMFS; on multivariate analysis, the type of axillary lymph node metastases was an additional significative factor. There was not relationship between pN0i+ and the development of DM. Surprisingly, patients with pN1mi had a 2.8 higher risk for developing DM than pN1 patients. pN1 patients receive more AST than pN1mi (75% and 22%), however AST was not prognostic (p=0.49).Conclusion:In our series, patients with pN1mi were associated with a worse prognosis related to DMFS compared to pN1. Use of AST and/or biological primary tumor characteristics could explain this paradoxical result. Longer follow-up and larger series are needed to determine the prognostic significance of axillary occult metastases.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 308.

Predictive Factors for Positive Non-Sentinel Nodes Following a Positive Sentinel Node Biopsy: NSABP B-32

Background: Following a positive sentinel node biopsy (SNB), current guidelines recommend an axillary dissection (AD) regardless of SN metastatic tumor size. In the majority of clinically node negative patients the risk for positive non-sentinel axillary nodes (NSN) is low. Predictive factors for positive NSNs following a positive SNB are analyzed in NSABP B-32 with inclusion of SN metastatic tumor size.Materials and Methods: After stratification, women with operable invasive breast cancer and clinically negative nodes were randomized to Sentinel Node Resection (SNR) with immediate conventional Axillary Dissection (AD) [Group 1] or to SNR without AD [Group 2]. Group 2 patients with positive SNs underwent AD. A multivariate analysis of SN positive patients from both groups for whom both a SNR and an AD had been performed was used to assess the need for AD following SNB. Nodes were classified as either SNs or NSNs, defined as all axillary dissection nodes plus any intramammary or other nodes that were not resected as SNs.Results: Between May 1999 and February 2004, 5,611 patients were entered into NSABP Protocol B-32. There were a total of 1,361 SN positive patients with AD from both groups. Data from 1,166 patients were available for multivariate analysis which included SN metastatic tumor size in 735 patients: 424 patients with macrometastaes (&gt;2 mm) and 311 with micrometastases (&lt;2 mm). In 626 patients SN metastatic size was unknown.In patients with positive SNB, results from the final multivariate model based on 653 patients with known covariate values indicated clinical tumor size was a significant predictor for positive NSN (p=0.044, OR: 1.17). Lymphovascular invasion was a significant predictor for positive NSN (p=0.0004, OR: 1.85). SN metastatic tumor size (Macro vs Micro) was a highly significant predictor for positive NSN (p&lt;0.0001, OR: 3.42). Age at study entry, treatment type, proposed type of surgery, HER-2 status, and location of tumor were not significant multivariate predictors for positive NSN. Predictive modeling for positive NSN probability will be presented.Conclusion: Completion AD following a positive SNB, although helpful in prognosis and treatment planning, may not be required in patients with small tumors, absence of lymphovascular invasion, and micrometastases.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 301.

[Preoperative concomitant radiochemotherapy in bulky carcinoma of the cervix: Institut Curie experience]

PURPOSE

To evaluate the treatment results of patients (pts) with Figo stage IB2, IIA, IIB cervical carcinoma (CC) treated with preoperative radiochemotherapy, followed by extended radical hysterectomy.

PATIENTS AND METHODS

Retrospective study of 148 women treated at the Institut Curie for operable Figo Stage IB2 to IIB, biopsy proved CC. Among them, 70 pts, median age 46 years, were treated using the same regimen associating primary radiocisplatinum based chemotherapy, intracavitary LDR brachytherapy, followed by extended radical hysterectomy. Kaplan-Meier estimates were used to draw survival curves. Comparisons of survival distribution were assessed by the log-rank test.

RESULTS

Complete histological local-regional response was obtained in 56% of the pts (n=39). Residual macroscopic or microscopic disease in the cervix was observed in 28 pts (40%). All but one had in situ microscopic residual CC. Lateral residual disease in the parametria was also present in nine pts, all with residual CC. Pelvic lymph nodes were free from microscopic disease in 56 pts (80%). Eight of 55 (11%) radiological N0 patients had microscopic nodal involvement, as compared to 6/15 (40%) radiological N1 (p=0.03). Seventeen pts (25%) had residual cervix disease but negative nodes. After median follow-up of 40 months (range, 8-141), 38/70 patients (54.1%) are still alive and free of disease, six (8.6%) alive with disease, and 11 (15.8%) patients were lost for follow-up but free of disease.

CONCLUSION

The treatment of locally advanced CC needs a new multidisciplinary diagnostic and treatment approach using new therapeutic arms to improve the survival and treatment tolerance among women presenting this disease.

Do isolated cells (pN0i+) in the sentinel lymph node change the post-operative management in breast cancer?

Abstract #206

Background: immunohistochemical (IHC) analysis of the sentinel lymph node (SLN) allows detection of occult metastases not routinely diagnosed by conventional techniques. There is, however, no consensus concerning the post-operative management of those patients with IHC-positive (pN0i+) nodes: should one re-operate, change the medical treatment or alter the irradiation fields?&#x2028; Patients and methods: 2692 patients with early invasive breast cancer underwent conservative treatment with SLN biopsy between 2000 and 2006. SLN were evaluated with frozen section followed by serial-section HES and IHC if HES showed no tumour cells. Lymph node staging followed the accepted pTNM classification: pN0, pN0i+ (≤ 0.2mm, IHC+), pNmi (0.2-2mm) and pN1a (&gt; 2mm). In 1506 patients with T1pN0 tumours : 143 were pN0i+, that is 10%. We compared the post-operative management of pN0 patients, who had no completion axillary dissection (CAD), to those pN0i+ who did. All positive SLNs underwent CAD according to our institutional protocol.&#x2028; Results: 15 of 143 (10.5%) pN0i+ patients showed metastases in their CAD; a single node in 10 cases, 2-3 in 4 and &gt; 3 in one patient. Univariate analysis showed chemo- and hormono-therapy to be more frequently administered in pN0i+ (24.5% vs. 77.6%) compared to pN0 (9.1% vs. 55.8%) patients; p &lt; 0.0001. Irrespective of the result of CAD, pN0i+ patients had significant modifications in their fields of lymphatic irradiation at the internal mammary (43.6% vs. 23.5%), supra-clavicular (40.9% vs. 21.5%) and sub-clavicular (13.5% vs. 3.7%) areas; p &lt; 0.0001. Other predictive factors showed a similar pattern including age &lt; 50 years (31.5% vs. 18.6%), tumour size bigger (1.51cm vs. 1.16 cm) and lymphovascular invasion (27.5% vs. 11.6%); p &lt; 0,0001. After multivariate analysis, the sole decisive factor for chemotherapy between the two groups was the presence of nodal metastasis in CAD. The duration of this study is, however, insufficient to comment on the long-term implications for pN0i+ patients.&#x2028; Discussion: immunohistochemistry alone plays a decisive role in favour of chemotherapy in N+ supplementary AD in only 10% of pN0i+ (15/143) patients. However, this concerns only 1% (15/1506) of those undergoing IHC so may have significant resource implications and other factors were found to be more influential. Moreover, pN0i+ patients underwent additional lymphatic irradiation, to all 3 fields, more frequently.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 206.

Genomic and transcriptomic differences between lobular and luminal ductal invasive carcinoma

Abstract #2039

Background: Invasive lobular carcinomas (ILCs) of the breast are characterized by morphological and phenotypical features such as small, non cohesive, estrogens receptors positive cells, low proliferation rates with a metastatic spreading in numerous and different unusual metastatic sites as compared to invasive ductal carcinomas (IDCs) (Ferlicot et al, 2004). We have previously shown that ILCs presented the same outcome than IDCs (Sastre-Garau et al, 1996). Beyond E-cadherin genomic inactivation, little is known about the underlying genomic and transcriptomic alterations that may discriminate both subtypes.&#x2028; Aims of the study: To get an insight into ILC biological specificities, we performed a combined genomic (aCGH), transcriptomic (Affymetrix U133A+B) and phenotypic analysis of a series of 24 lobular carcinomas and compared it to a series of 41 ER-positive IDCs.&#x2028; Results: Analysis of genomic copy number showed that ILCs and IDCs shared gains of the 1q11-q43 region and losses of 16q12.1-q24.2 and 17pter-p13.1 regions. ILCs presented the 22q12-q13 loss but not the 16pter-p11.2 gain and 11q23-q24 loss as observed in IDCs. Eight different regions of high level amplifications were found in 29% of ILC cases (7/24 cases). Only one region of amplification was recurrent and observed in 5 out of 24 tumors (21% of the cases). This recurrent region of amplification was localized on the 11q13.2 region and encompassed the Cyclin D1 (CCND1) and Cortactin (CTTN) genes. ILCs and IDCs had comparable overall survival rates, however, unsupervised hierarchical clustering of transcriptomic data showed that ILCs and IDCs clustered apart. Genes involved in cell adhesion and motility, lipid/fatty transport and metabolism and electron transport were differentially expressed between the two groups.&#x2028; Conclusions: This integrated analysis emphasized the biological differences between ILC and IDC and highlighted genes of interest that could be useful for diagnosis, and could be new putative therapeutical targets.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 2039.

Long-term outcomes after invasive breast tumor recurrence (IBTR) in women with DCIS in NSABP B-17 and B-24

520

Background: DCIS patients treated with lumpectomy have a very favorable outcome but are at risk for IBTR. Local control is improved by radiotherapy (RT) and adjuvant tamoxifen (TAM). Local failures, specifically invasive IBTRs (I-IBTR), may impact on long-term outcome. We present long-term outcome results from a cohort of DCIS patients from two NSABP randomized trials. Patients and Methods: A total of 2,615 women with primary DCIS from NSABP B-17 and B-24 (randomized from 1985 to 1994) were included. Median follow-up was > 12 yrs. In B-17 treatment was lumpectomy (LO, 403) or lumpectomy with whole breast irradiation (LRT, 410). In B-24 patients received LRT (901) or LRT plus TAM [901]. Hazard ratio and cumulative incidence of IBTR were examined by treatment. Mortality hazard was evaluated in relation to prior IBTR. Results: IBTR was a first failure in 465 patients (243 invasive, 222 noninvasive). The 12 year cumulative incidence of all IBTRs was 32.9% for LO, 15.8% LRT, and 12.5% LRT+TAM. RT significantly reduced I-IBTR (LRT/LO hazard ratio (HR) = 0.39; 95% confidence interval (CI) =0.26 to 0.59). TAM conferred additional benefit on I-IBTR (LRT+TAM/LRT HR=0.68; 95% CI= 0.48 to 0.97). Overall mortality was low. Women with I-IBTR had a two-fold greater mortality risk relative to those without I-IBTR (HR=2.08; 95% CI = 1.46 to 2.98). The effect was greater for LRT patients (HR=3.04; 95% CI= 1.92 to 4.84) than for LO patients (HR=1.17; 95% CI = 0.57 to 2.39). For LRT+TAM patients, the effect was similar to that for LRT patients HR=1.91; 95% CI= 0.76 to 4.78). Conclusions: As in cases of I- IBTR after an invasive index tumor, the occurrence of an I-IBTR with a DCIS index tumor, particularly after RT, confers increased risk for subsequent mortality.

No significant financial relationships to disclose.

An update on breast cancer prevention trials

In recent years, the question of whether breast cancer can be prevented has been examined in a number of large clinical trials, employing either selective estrogen receptor modifiers such as tamoxifen and raloxifene or aromatase inhibitors. In this paper, we review the most prominent studies, all of which are either under way or in follow-up.

Traitement cœlioscopique des tumeurs frontières (borderline) de l'ovaire : analyse d'une série de 54 patientes et implications thérapeutiques

OBJECTIVE

The aim of this study is to assess the clinical outcomes of laparoscopic treatment of borderline ovarian tumor (BOT).

PATIENTS AND METHODS

Retrospective analysis of 54 patients treated using a laparoscopic approach for a BOT between January 1984 and January 2002.

RESULTS

A conservative management was initially performed in 45 patients (83%). Twenty-six patients underwent a reassessment surgery and 7 (27%) of them were upstaged following this procedure. Seven (13%) patients recurred in a remaining ovary following conservative surgery (5 patients) or on the peritoneum (2 patients). Three port-site localizations were observed. None of the patients treated with conservative management had recurrent disease under the form of ovarian carcinoma. Nine spontaneous pregnancies were observed in 6 patients from a group of 19 patients desiring pregnancy. All patients are today alive and disease-free.

DISCUSSION AND CONCLUSION

Our study suggests that laparoscopic treatment could be safely performed in young patients with early stage BOT. Such procedure should be further evaluated in patients with BOT and peritoneal implants.

Prognosis of stage III or IV primary peritoneal serous papillary carcinoma

AIMS

To study the prognosis of patients with stage IIIC/IV primary peritoneal serous papillary carcinoma (PSPC) (study group) compared with that of patients with epithelial ovarian carcinoma (EOC) (control group).

METHODS

A retrospective case-control study including a study group of 37 patients who were matched with a control group of 37 patients. Patients were matched for the histologic subtype (serous tumor), tumor stage, tumor grade, residual disease at the end of debulking surgery (initial or interval) and age (+/-5 years).

RESULTS

Debulking surgery was performed initially or at interval surgery in respectively, 10 and 27 patients in the study group and 17 and 20 in the control group. All patients were treated with platinum-based chemotherapy (combined with paclitaxel in 33) in both groups. The overall survival rate at 3 years in the study and control groups was, respectively, 60% versus 55% (NS). However, event-free survival rates at 3 years (CI 95%) were statistically different (respectively, 29% in the study group versus 16% in the control group: p=0.008).

CONCLUSIONS

Peritoneal disease is more bulky in patients with PSPC. Neoadjuvant chemotherapy is more often required to achieve optimal debulking surgery in PSPC. Overall survival of patients with PSPC is similar to that of their EOC counterparts. Thus, the management of PSPC should not be different from that of advanced stage EOC.

Le curage de l'aisselle avec capitonnage musculaire sans drainage

OBJECTIVE

Axillary padding without drainage appeared to be a valuable alternative technique to vacuum drainage. The technique employs local muscles or the axillary aponeurosis for padding. We report here the clinical evaluation of muscular padding without drainage. The analysis of these results prompted us to also do a literature search for other alternatives aimed at reducing morbidity due to vacuum drainage.

PATIENTS AND METHODS

Muscular padding was prospectively performed by 8 different surgeons on a total of 152 patients at the Centre Rene-Huguenin (Saint-Cloud, France). Follow-up has attained 3.5 years. A comparative assessment of pain was conducted in 30 patients operated on with vacuum drainage.

RESULTS

This technique is easy to learn and reproducible. It facilitates post-operative follow-up, always allowing discharge at the 2nd or 3rd post-operative day without any home nursing. The late sequels are not increased. In contrast, pain was twice more intense during the first post-operative weeks compared with vacuum drainage, and the seroma rate was also increased.

DISCUSSION AND CONCLUSION

Despite good efficacy, this worsening of pain is a major obstacle to the routine use of muscular padding. A technical improvement has been published very recently where the axillary aponeurosis was used to pad the axilla. It seems to be equally efficient but less painful than muscular padding. This technique is under clinical evaluation and could appear as a valuable option to vacuum drainage. Other alternatives are discussed. Most studies lack a direct comparison with vacuum drainage and a satisfactory evaluation of quality of life is also omitted. New studies with quality of life scales are ongoing. They should allow us to choose options that take this aspect into account in the future.

Laparoscopic myomectomy: predicting the risk of conversion to an open procedure

BACKGROUND

Laparoscopic myomectomy (LM) has some advantages over laparotomy; however, it is reputed to be technically difficult, and the risk of conversion to laparotomy might be an obstacle in using this procedure. The aim of this study was to identify the pre-operative factors affecting the risk of conversion to an open procedure (either laparoscopic assisted myomectomy or laparotomy), and to develop a simple prediction model based on available pre-operative data with the use of multiple logistic regression.

METHODS

A total of 426 women presenting with a subserous or intramural myoma measuring 20 mm or more underwent LM between March 1989 and October 1999. Of these patients, 378 had successful LM. Forty eight patients [11.3%, 95% confidence interval (CI) 8.3--14.3] had a conversion to an open procedure. A total of 265 women had adequate pre-operative ultrasonography (US) and were used for the analysis.

RESULTS

The best prediction model included four pre-operative factors that were found to be independently related to the risk of conversion: size > or = 50 mm at US (adjusted OR = 10.3; 95% CI = 2.8--37.9), intramural type (adjusted OR = 4.3; 95% CI = 1.3--14.5), anterior location (adjusted OR = 3.4; 95% CI = 1.3-9.0) and pre-operative use of gonadotrophin-releasing hormone (GnRH) agonists (adjusted OR = 5.4; 95% CI = 2.0--14.2). The regression coefficients were then scaled and rounded to integers to provide an estimate of the risk for conversion. For a given patient with selected characteristics the predicted risk varied from 0--73%.

CONCLUSIONS

This prediction model provides a useful tool that enables multiple criteria to be taken into account simultaneously to help select cases for LM. GnRH agonists should been used only in selected cases. US evaluation is essential before performing LM.